Harkness Fellows Blog

The Commonwealth Fund’s Harkness Fellowships provide a unique opportunity for mid-career health services researchers and practitioners to conduct original research in the US, and work with leading US health policy experts. The UK Harkness Fellowships are supported by the Nuffield Trust and the National Institute for Health Research Service Delivery and Organisation Programme (NIHR SDO).

We encourage current UK Harkness Fellows to blog about their experiences in the US for both the Nuffield Trust and the Health Service Journal. The views expressed in this blog are the authors' own, and do not necessarily represent those of the Commonwealth Fund, the Nuffield Trust or NIHR SDO.

Lessons from the U.S

It has always been difficult to distil down the improvement goal of healthcare. Back in 2008, Don Berwick and colleagues at the U.S. Institute for Healthcare Improvement coined the phrase 'the Triple Aim' to describe succinctly what improvement efforts in healthcare should aim to achieve.

In 2015 Kaiser Permanente wants to be the “best place to start and grow your family.” Leading this vision is a doctor. With over nine million members, spread across eight regions and six states, Kaiser is one of the US’s largest health management organisations, but inevitable tensions exist across its three separate entities. This requires leadership; a great deal of which comes from the medical profession.

Why does doctor leadership work in the US?

A new breed of healthcare provider is subverting the model of American healthcare for its most needy patients, whilst improving care and reducing costs.

Need a lift to the doctor? If you’re a patient of CareMore in the American southwest, they may well chauffeur you there. Worried about falling over in your sitting room? They’ll fit you a new carpet. Not sure when to pop your next pill? Don’t worry – your medicine box will sing you a tune when the time comes.

Last Sunday I drove to my local MinuteClinic in Cambridge, Massachusetts. I parked outside the CVS pharmacy, right by Dunkin’ Donuts and Chipotle Mexican Grill. I didn’t need an appointment. Inside the store a large screen displayed the price list. $79 to $99 for treatment for minor illnesses like ear infections or strep throat. $59 for diabetes screening. $28 for a TB test. I entered my details on a touch screen. Five minutes later, a nurse practitioner was ready to see me.

Of the 13 million Americans that need long-term care, only 13 per cent have received help in paying for these services. The situation is set to become even more challenging, as the proportion of Americans over the age of 65 is...

When I arrived in Boston as one of the 2012-13 Harkness Fellows I had no idea what learning I would want to bring back from the US health system to the UK. The Fellowship provides a wonderful opportunity to stand outside the UK as well as the US system and look at the strengths and weaknesses of both.

The greatest strength that I have so far seen in the US system is a genuine commitment to innovation.

One of the most notable features about American health care is the use of fee-for-service as a payment model. In return for a consultation with a physician, outpatient procedure, or hospitalisation, the insurer (or the patient) pays for the individual services.

As fee-for-service operates on an individual service basis, the incentives for doctors to make more money are relatively straightforward – especially if a physician is the equivalent of a single-handed GP or private specialist – the more billable the activity, the higher the payment.

The idea of being accepted to do a Harkness Fellowship was almost inconceivable. I submitted my application with bated breath, not wanting to let myself really think that there was any chance it could become a reality.

The email inviting me to interview was a week later than scheduled, and in this time I convinced myself it wasn’t going to happen for me.

Then there was the elation on making it onto the shortlist, followed by the dread of being grilled by such an incredible panel of health care experts. For the next month, everything was focused on...

Over the last 12 months I’ve been researching the impact of competition policy on delivery system innovation and payment reforms that promote greater integration. My question has been: how might policy makers, regulators and health care leaders work constructively to produce an informed and proportionate competition regime applied to the NHS?

In the US, health care providers are united in the view that competition concerns – namely the fear of...

You might think that here in the US, we’d all been waiting with baited breath for the decision of the Supreme Court regarding the constitutionality of the Affordable Care Act (ACA).

What would this mean for Health Information Exchanges? Would the 50 million uninsured remain uninsured? If not the ACA, then what? But even though these were real concerns, many people were just simply getting on...

What will 2012 hold for health care? Let’s ignore for now the inevitable political controversy and ideological teeth-grinding over health reform that will no doubt continue on both sides of the Atlantic.

If we focus instead on the payment and delivery system reforms that will preoccupy the health sector, then the concept of integrated care is likely to be somewhere near the top of the list (again).

Here, in the US, this means 2012 will be the year of the ACO – ‘the accountable care organisation’ – widely regarded as a cornerstone of the current reform agenda. The past...

I have been in Boston for a few months now, and the weather has turned. We were robbed of a spectacular New England Fall. Some blamed the hurricane; some the earthquake; the more scientific amongst us, the temperature.

Fall was delayed as the chlorophyll rich leaves persisted due to the stimulation of an atypically warm and sunny October/November. After weeks of patiently waiting for the leaves to change colour, they changed abruptly and fell almost without anyone noticing.

Around the same time, Don Berwick was quietly making ready his notes for his successor as he was...

Breakfast with Lansley. Lunch with Berwick. A chance meeting with Obama (Michelle, not Barack). And dinners with more top-rate health care academics, analysts and policy-makers from around the world than would have seemed possible just a few short weeks ago.

With this has come slides – lots of slides. Slides showing how bad things are here. Slides showing how good things are there. Slides showing how Japan is doing its best to make everyone look average, and slides showing how India plans to break the mould in eye-...

Over the last year, people have often asked me if being a Harkness Fellow was what I expected. It sounds rather a cliché to say it exceeded my expectations, but it genuinely has. The hospitality of the Commonwealth Fund, my mentors and many new American friends this year has left me with incredibly fond memories of the US and many friendships I hope to continue.

One of my mentors has a favourite quote from Confucius: “If there are three men in the street in front of you, two of them could be your teachers”. I have met many teachers this year and am grateful to each one of them. The...

Prior to reading Personal Health Records: a guide for clinicians I was not clear exactly what a personal health record (PHR) entailed. I suspect I am not alone. PHRs are relevant for all stakeholders in health care. If intrigued by how they are relevant for you, read on.

In the Californian sun, near a beach 20 miles from the Mexican border, a man and a woman are talking:

“You don’t respect me – you can’t even look me in the eye.”

“But you just don’t understand my priorities – I need you to get to the point, to be ready for me.”

Not some US daytime soap opera, but the dialogue generated by a Kaiser Permanente away day aiming to improve communication between doctors and nurses. Using a parallel with “Men are from Mars, Women are from Venus”, the facilitator explains how nurses tend to be more interested in the quality of interactions...

If the stereotypes of US healthcare were to be believed, then at least one middle-aged New York taxi driver would not be alive and working today. Like many of New York’s cabbies, waiters, kitchen staff and stall keepers, he is an undocumented (illegal) resident who spent his life savings escaping Mexico to start afresh in the US. He wouldn’t initially go to the hospital with his chest pain because he was afraid that they would ask for his papers, and anyway, he couldn’t afford to pay insurance or co-pays or deductibles, never mind the raw cost of the healthcare he clearly needed. But...

Founded in 1908, the Harvard Business School is consistently ranked among the top business school rankings globally. Since 1920, one of the ways Harvard Business School has differentiated itself is by developing and pioneering the case method of teaching. For this approach, teaching is focused around cases. Each case presents a real life complex business situation, containing sizeable qualitative and quantitative evidence to enable the reader to develop analyses and arguments. This method is based on the premise that in business – including the business of health care - there is no one...

Last week I attended the 22nd Annual National Forum on Quality Improvement in Health Care, hosted by the Institute for Healthcare Improvement (IHI) in Orlando, Florida. I first visited IHI’s HQ in Boston soon after I began my Harkness Fellowship, in July 2010. I was excited to visit the organization, after hearing and reading so much about it over the last few years working within the NHS. The office environment reflects the culture of the organization. There are no walls. Literally. It is open-plan, with central communal areas supplying comfy sofas and sodas. Inspiring quotes adorn...

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The Nuffield Trust is an independent health charity. We aim to improve the quality of health care in the UK by providing evidence-based research and policy analysis and informing and generating debate.